During an assessment of the cranial nerves, the nurse finds the following: Asymmetry when the client frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and an escape of air from the right side when the client puffs their cheeks. This would indicate the dysfunction of which of the cranial nerves?
Motor component of IV (Trochlear)
Motor and sensory components of XI (Accessory)
Motor component of VII (Facial)
Motor component of X (Vagus) and sensory component of XII (Hypoglossal)
The Correct Answer is C
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.
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View Related questions
Correct Answer is A
Explanation
A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.
B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.
C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.
D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings
Correct Answer is C
Explanation
A) Chronic pain: Chronic pain is defined as pain that lasts for an extended period, often longer than three months, and is usually associated with conditions that are ongoing or recurring. The client’s symptoms, including sudden-onset severe pain and accompanying acute symptoms like nausea and vomiting, do not align with the characteristics of chronic pain.
B) Intractable pain: Intractable pain refers to pain that is resistant to treatment and does not respond well to analgesics or other interventions. While the client's pain is severe, the sudden onset and associated symptoms suggest a specific acute process rather than a pain condition that is inherently resistant to treatment.
C) Acute pain: Acute pain is characterized by its sudden onset and typically corresponds to a specific injury or condition, often with accompanying physiological responses such as nausea and restlessness. The client’s severe pain rating of 10, along with nausea and vomiting, strongly indicates that they are experiencing acute pain, likely related to an underlying acute abdominal condition.
D) End-of-life pain: End-of-life pain usually occurs in patients with terminal illnesses and is often managed with palliative care strategies. The client’s sudden onset of severe pain and accompanying symptoms indicate a different situation, likely not related to a terminal condition.